Retraining Visual Processing Skills To Improve Driving Ability After Stroke

Crotty M, George S. Retraining visual processing skills to improve driving ability after stroke.

Objective

To evaluate the effectiveness of retraining using the Dynavision on driving performance of people with stroke.

Design

Randomized controlled trial.

Setting

Outpatient rehabilitation clinic in Australia.

Participants

People with stroke (N=26) referred for driving assessment.

Interventions

Eligible participants were randomized to either receive retraining with the Dynavision apparatus for 18 sessions or to receive no intervention and go onto a waitlist.

Main Outcome Measures

The primary outcome was an assessment of on-road ability. Secondary outcomes included measures of response speed, visual scanning, and self-efficacy. All assessments were conducted by assessors blinded to group assignment.

Results

No significant difference (P=.223) was found between the intervention and control groups in results of on-road assessment in terms of pass or fail; the primary outcome measure; or the results on the secondary outcome measures of response speed, visual scanning, and self-efficacy.

Conclusions

In this small trial, training underlying skills (such as executing a continuous wide scan, combining motor and visual processing into a motor response) using the Dynavision apparatus did not improve the outcomes of an on-road assessment for people after strokes. Larger trials are needed to evaluate devices that claim to retrain underlying skills related to driving.     

Stem cells in the aetiopathogenesis and therapy of rheumatic disease

Animal models of autoimmune disease and case reports of patients with these diseases who have been involved in bone marrow transplants have provided important data implicating the haemopoietic stem cell in rheumatic disease pathogenesis. Animal and human examples exist for both cure and transfer of rheumatoid arthritis, systemic lupus erythematosus (SLE) and other organ-specific diseases using allogeneic haemopoietic stem cell transplantation. This would suggest that the stem cell in these diseases is abnormal and could be cured by replacement of a normal stem cell although more in vitro data are required in this area. Given the morbidity and increased mortality in some patients with severe autoimmune diseases and the increasing safety of autologous haemopoietic stem cell transplantation (HSCT), pilot studies have been conducted using HSCT in rheumatic diseases. It is still unclear whether an autologous graft will cure these diseases but significant remissions have been obtained which have provided important data for the design of randomized trials of HSCT versus more conventional therapy. Several trials are now open to accrual under the auspices of the European Bone Marrow Transplant Group/European League Against Rheumatism (EBMT/EULAR) registry. Future clinical and laboratory research will need to document the abnormalities of the stem cell of a rheumatic patient because new therapies based on gene therapy or stem cell differentiation could be apllied to these diseases. With increasing safety of allogeneic HSCT it is not unreasonable to predict cure of some rheumatic diseases in the near future.     

Overseas Visitor Deaths in Australia, 2001 to 2003

Background.  The health and safety of international visitors remain an important issue for Australia and other tourist destinations. The death of visitors remains an important indicator of safety. The aim of this study was to provide updated figures on deaths of overseas travelers in Australia.
Methods.  Data were sourced from the Australian Bureau of Statistics concerning deaths of overseas visitors for the years 2001 to 2003.
Results.  There were 1,068 overseas visitor deaths (701 males, 66%) during the study period 2001 to 2003. Death by natural causes increased with age, while deaths associated with accidents were more frequent among younger age groups. The majority of deaths were from natural causes (782, 73%), particularly ischemic heart diseases (26%). There were a total of 247 accidental deaths (23% of all deaths) with the main causes being transportation accidents (14% of all deaths) and accidental drowning/submersion (5% of all deaths). The countries contributing the most deaths were the UK (247, 23%), New Zealand (108, 10%) Melanesia/Micronesia (95, 9%), and the United States (57, 5%).
Conclusions.  Australia remains a relatively safe destination for international travelers, at least in terms of fatalities, which appear to be declining. Most deaths of overseas tourists in Australia are due to natural causes with cardiovascular disease being the predominant cause of death in this group. Accidents remain the most common preventable cause of death of travelers, with road and water safety being the major issues. It is important that tourism and travel medicine groups continue to advocate for improved health and safety of international travelers visiting Australia.     

Quality in health care: outcomes

The clinical anaesthesiologist has an important role in achieving quality in healthcare outcomes. Exploration of the definitions and frameworks for understanding health, healthcare, quality, and outcomes highlights the different perspectives of the key stakeholders. The common desired quality in healthcare outcome is to improve the existing health system. This requires measuring and managing performance in a cycle and understanding the systems' approach to health. The clinical anaesthesiologist is able to contribute at each of the different stages of their career from trainee to respected clinical leader. Ideally the contributions should be through a continuous, strategic, voluntary and pro-active approach using existing tools to analyse the current clinical service to determine how to reach the ideal. Apart from professional pride, the escalating costs of healthcare and the need for accountability to our profession and the public are compelling reasons to contribute towards improving quality healthcare outcomes.     

Computer programs to estimate overoptimism in measures of discrimination for predicting the risk of cardiovascular diseases

Background Development of chronic disease risk prediction models has become a growing area of research in recent years. The internal validity of such models is sometimes lower than estimated from the development sample. Overfitting or overoptimism of the developed model and/or differences between the samples are likely causes for this. For modelling of an uncommon outcome, bootstrapping for overoptimism is the preferred method for afterwards shrinking of regression coefficients and the model's discrimination and calibration for overoptimism. However, computer programs for different types of bootstrap validation are not readily available. We developed two SAS macro programs – one for the simple bootstrap that compares the discriminatory performance of the Cox proportional hazards model from the original sample in bootstrap samples; and another (which is more efficient), known as stepwise bootstrap validation, that makes the same comparison but from models developed by variable selection from bootstrap samples in the original sample. These are illustrated through an example from cardiovascular disease (CVD) risk prediction. Methods Two SAS macro programs for Cox proportional hazards model using Proc PHREG were developed for estimating overoptimism in Harrell's C and Somers' D statistics. The computer programs were applied to data on CVD incidence for a Framingham cohort that combined both the original and offspring exams. The risk factors considered were current smoking, diabetes, age, sex, systolic blood pressure, diastolic blood pressure, total cholesterol, high‐density lipoprotein cholesterol, triglycerides and body mass index. Results The degree of overoptimism in both Harrell's C and Somers' D statistics were low. Both these statistics were corrected for overoptimism by subtracting overoptimism from their observed values. Between the two bootstrap validation algorithms, the degree of overoptimism was estimated to be higher for stepwise bootstrap validation. Conclusion The programs are very useful for evaluating the ‘overoptimism corrected’ predictive performance of Cox proportional hazards model.